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DEBATE?DEBATE?
THERE IS NO THERE IS NO DEBATEDEBATE
Traditional Perioperative CareTraditional Perioperative Care
•StarveStarve
•StressStress
•DrownDrown
Enhanced recovery after surgeryEnhanced recovery after surgery
Fu
nct
ion
al c
apac
ity
Fu
nct
ion
al c
apac
ity
SurgerySurgery Multi-modal interventionMulti-modal intervention
Traditional careTraditional care
DaysDays WeeksWeeks
Preop
Audit of compliance & outcomes
HomeSurgery
↨Anesthesia
WardHDU
CLINIC
PATIENT’S JOURNEY
KCH Fearon 2004
Preadmissioncounselling
Selective bowel-prep
CHO- loading/no fasting
No - premed
No NG tubes
Thoracic epidural Anaesthesia
Short-acting Anaesthetic agent
Avoidance ofSodium/fluid overload
Short incisionsWarm air bodyheating in theatre
Standard mobilisation
Non-opial oralAnalgetics/NSA ID`s
Prevention of nausea and vomiting
Stimulation of gut mobility
Early removal ofcatheters/drains
Perioperativeoral nutrition
Audit of compliance/outcomes
ERAS
Core Protocol
FLUIDSFLUIDSFOODFOOD
BALANCED IS BALANCED IS BETTERBETTER
ELECTIVE SURGERYELECTIVE SURGERYRESUSCITATIONRESUSCITATION
WET IS BESTWET IS BEST
Post-op Weight GainPost-op Weight GainFollowing Colorectal ResectionFollowing Colorectal Resection
Lobo et al, Lancet Lobo et al, Lancet Brandstrup et al, 2002; Brandstrup et al, 2002; 359359: 1812-18 : 1812-18 Annals Surg 2003; Annals Surg 2003; 238238: 641-8: 641-8
3-6kg
KCH Fearon 2004
HypothesisHypothesis
Fluid/SalineFluid/Saline
OverloadOverload
Hypoalbuminaemia/Acidosis/HyperchloraemiaHypoalbuminaemia/Acidosis/Hyperchloraemia
Gut oedema/MalfunctionGut oedema/Malfunction
Delayed recoveryDelayed recovery
Effect of salt and water balance in recovery of Effect of salt and water balance in recovery of gastrointestinal function after elective colonic gastrointestinal function after elective colonic
resectionresection
20 colonic resection20 colonic resection
patientspatients
1010 10 10
Standard IVStandard IV Restricted IV*Restricted IV*
fluidsfluids fluids fluids
(* 2l H(* 2l H220 and 77mmol NaCl)0 and 77mmol NaCl)
Lobo et al, 2002 Lobo et al, 2002 Lancet; 359: 1812-8Lancet; 359: 1812-8
Effect of fluid and salt restriction in post-Effect of fluid and salt restriction in post-op recoveryop recovery
-2-2
-1-1
00
11
22
33
44
55 Standard GroupStandard Group
Restricted GroupRestricted Group
p<0.0001p<0.0001
Ch
ange
in w
eigh
t (k
g)C
han
ge in
wei
ght
(kg)
0 1 2 3 4 50 1 2 3 4 5Postoperative daysPostoperative days
Standard GroupStandard GroupRestricted GroupRestricted Group
2525
3030
3535
4040
Ser
um
alb
um
in (
g/L
)S
eru
m a
lbu
min
(g/
L)
p=0.01p=0.01
PreopPreop
1 2 3 4 5 61 2 3 4 5 6
Postoperative daysPostoperative days
Effect of fluid and salt Effect of fluid and salt restriction in post-op recoveryrestriction in post-op recovery
Soli
d p
hase
gas
tric
em
ptyi
ng
Soli
d p
hase
gas
tric
em
ptyi
ng
tim
e T
tim
e T
5050 (
mm
) (
mm
)
250250
200200
150150
100100
5050
00
n=10n=10n=10n=10
p=0.028p=0.028
Standard Restricted Standard Restricted Group GroupGroup Group
Liq
uid
phas
e gs
ric
empt
yin
g L
iqui
d ph
ase
gsri
c em
ptyi
ng
tim
e T
tim
e T
5050 (
min
) (
min
)
200200
150150
100100
5050
00
n=10n=10n=10n=10
p=0.017p=0.017
Standard Restricted Standard Restricted Group GroupGroup Group
Post-op Fluid ManagementPost-op Fluid Management
TRADITIONALTRADITIONAL
BALANCEDBALANCED
4-6L4-6L
2-3L2-3L
2-3L2-3L1-2L1-2L
OPERATIONOPERATION POST-OPPOST-OP
2-4d2-4d
1-2d1-2d
What is the evidence base What is the evidence base to suggest that to suggest that
BALANCED fluid BALANCED fluid management can management can
improve outcomes?improve outcomes?
Effects of IV fluid restriction on Effects of IV fluid restriction on post-op complicationspost-op complications
172172Colorectal resectionColorectal resection
patientspatients
8686 8686 Standard IVStandard IV Restricted IV Restricted IV fluidsfluids fluids fluids
7272 69 69 competedcompeted completed completed
Brandstrup et al, Brandstrup et al, 2003; 2003; 238238: 641-8: 641-8
Number of Patients with Complications Number of Patients with Complications (Per-Protocol Analysis)(Per-Protocol Analysis)
Restricted Restricted GroupGroup
Standard Standard GroupGroup
p valuep value
Overall complicationsOverall complications 2121 4040 0.0030.003
Major complications Major complications †† 88 1818 0.0400.040
Minor complications Minor complications †† 1515 3636 0.0000.000
Tissue-healing complications Tissue-healing complications †† 1111 2222 0.0400.040
Cardiopulmonary complications Cardiopulmonary complications †† 55 1717 0.0070.007
Blinded AssessmentBlinded Assessment
Effect of Intra-operative Fluid Management Effect of Intra-operative Fluid Management on Outcome after Intra-abdominal Surgeryon Outcome after Intra-abdominal Surgery
Nisanerich et al 2005, Anaesthesiology; 103: 25-32Nisanerich et al 2005, Anaesthesiology; 103: 25-32
n=152n=152
n=75n=75 n=77n=77
RandomisedRandomised
Liberal regimenLiberal regimen(Bolus 10ml/kg followed(Bolus 10ml/kg followed
By 12ml/kg/hr)By 12ml/kg/hr)
Restricted regimenRestricted regimen(4ml/kg/hr)(4ml/kg/hr)
3.8 3.8 ± 1.2 L± 1.2 L
2.0 2.0 ± 0.5 L± 0.5 L
2.0 2.0 ± 0.5 L± 0.5 L
1.9 1.9 ± 0.5 L± 0.5 L
1.4 1.4 ± 1.0 L± 1.0 L
2.2 2.2 ± 0.5 L± 0.5 L
2.1 2.1 ± 0.5 L± 0.5 L
2.0 2.0 ± 0.5 L± 0.5 L
Intra-opIntra-op
Day 1Day 1
Day 2Day 2
Day 3Day 3
<0.001<0.001
N.S.N.S.
N.S.N.S.
N.S.N.S.
PP
Effect of Intra-operative Fluid Effect of Intra-operative Fluid Management on Outcome after Intra-Management on Outcome after Intra-
abdominal Surgeryabdominal Surgery
Nisanevich et al 2005, Anaesthesiology; 103: 25-32Nisanevich et al 2005, Anaesthesiology; 103: 25-32
OutcomeOutcome RestrictedRestricted LiberalLiberal PP
No. of pts with No. of pts with complicationscomplications
1313 2323 <0.05<0.05
Length of stay (d)Length of stay (d) 88 99 <0.01<0.01
Moved bowels (d)Moved bowels (d) 44 66 <0.001<0.001
If you Limit Intra-operative Fluids If you Limit Intra-operative Fluids (10ml/kg/hr), does Early Discontinuation of (10ml/kg/hr), does Early Discontinuation of
IV Fluids Influence Outcome?IV Fluids Influence Outcome?
Makay et al Makay et al (sumbitted)(sumbitted)
n=80n=80
ColorectalColorectal
n=41n=41 n=39n=39
STANDARDSTANDARD LIMITEDLIMITED3L H3L H220/d0/d
154mmol Na/d154mmol Na/d3d3d
2L H2L H220/d0/d
60mmol Na/d60mmol Na/d1d1d
Effect of Restricted Intra-op Effect of Restricted Intra-op Fluids Plus Discontinuation of IV Fluids Plus Discontinuation of IV
Fluids on Day 1Fluids on Day 1
Makay et al (submitted)Makay et al (submitted)
RestrictedRestricted ‘‘Liberal’Liberal’ PP
No of complicationsNo of complications 1414 1010 NSNS
Length of stay (day)Length of stay (day) 66 66 NSNS
Moved bowels (day)Moved bowels (day) 44 44 NSNS
BALANCEDBALANCEDISIS
BESTBEST
Postoperative early enteral Postoperative early enteral nutritionnutrition
Lewis BMJ 2001
Traditional Care Day1
ERAS Day1
Nygren Clin Nutr 2003
Food intake
0
400
800
1200
1600
1 2 3 4
Postop days
kcal
/ 24
h
Effect of ERAS on spontaneous Effect of ERAS on spontaneous oral diet oral diet
traditional care enhanced-recovery protocol
Complications, length of stay and readmissions Complications, length of stay and readmissions within 30 days of colorectal resectionwithin 30 days of colorectal resection
ERASERASn = 425n = 425
Traditional*Traditional*n = 451n = 451
PP
Anastomotic leak % Anastomotic leak % 4.24.2 3.93.9
Mortality %Mortality % 1.21.2 1.51.5
Actual length of stay (days) Actual length of stay (days) (median)(median) 55 88 <0.01<0.01
* Nygren et al Clin Nut 2005;24:455-461
ERAS GROUP
THE ENDTHE END